1. Define diagnostic reasoning
Reflective thinking because the process involves questioning one's thinking to
determine if all possible avenues have been explored and if the conclusions that are
being drawn are based on evidence.
Seen as a kind of critical thinking.
2. Discuss and identify subjective data?
What the patient tells you, complains of, etc.
Chief complaint
HPI
ROS
3. Discuss and identify objective data?
What YOU can see, hear, or feel as part of your exam.
Includes lab data, diagnostic test results.
Components of HPI
4. Discuss and identify the components of the HPI
Specifically related to the chief complaint only.
Detailed breakdown of CC.
OLDCART
5. What is medical coding?
The use of codes to communicate with payers about which procedures were performed
and why
6. What is medical billing?
Process of submitting and following up on claims made to a payer in order to receive
payment for medical services rendered by a healthcare provider.
7. What are CPT codes?
Common procedural terminology
Offers the official procedural coding rules and guidelines required when reporting
medical services and procedures performed by physician and non-physician providers.
8. What are ICD codes?
International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
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,NR 511 – FINAL EXAM STUDY GUIDE
9. What is specificity?
The ability of the test to correctly detect a specific condition.
If a patient has a condition but test is negative, it is a false negative.
If a patient does NOT have a condition but the test is positive, it is a false positive.
10. What is sensitivity?
Test that has few false negatives.
Ability of a test to correctly identify a specific condition when it is present.
The higher the sensitivity, the lesser the likelihood of a false negative.
11. What is predictive value?
The likelihood that the patient actually has the condition and is, in part, dependent upon
the prevalence of the condition in the population.
If a condition is highly likely, the positive result would be more accurate.
12. Discuss the elements that need to be considered when developing a plan
Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
13. Describe the components of Medical Decision Making in E&M coding
Risk
Data
Diagnosis
The more time and consideration involved in dealing with a pt, the higher the
reimbursement from the payer.
Documentation must reflect MDM!
evaluation and management (E&M)
14. Correctly order the E&M office visit codes based on complexity from least to most
complex
New patient: Established patient:
1. Minimal/RN visit: 99201 Minimal RN visit: 99211
2. Problem focused: 99202 Problem focused: 99212
3. Expanded problem focused: 99203 Expanded problem focused: 99213
4. Detailed: 99204 Detailed: 99214
5. Comprehensive: 99205 Comprehensive: 99215
15. Discuss a minimum of three purposes of the written history and physical in
relation to the importance of documentation
Important reference document that gives concise info about the pt's Hx and exam
findings.
Outlines a plan for addressing issues that prompted the visit. Info should be
presented in a logical fashion that prominently features all data relevant to the
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pt's condition.
Is a means of communicating info to all providers involved in the pt's care.
Is a medical-legal document.
Is essential in order to accurately code and bill for services.
16. Accurately document why every procedure code must have a corresponding
diagnosis code
Diagnosis code explains the necessity of the procedure code.
Insurance won't pay if they don't correspond.
17. Correctly identify a patient as new or established given the historical information
If that pt has never been seen in that clinic or by that group of providers OR if the
pt has not been seen in the past 3 years.
18. Identify the 3 components required in determining an outpatient, office visit E&M
code
Place of service
Type of service
Patient status
19. Describe the components of Medical Decision Making in E&M coding
Risk
Data
Diagnosis
The more time and consideration involved in dealing with a pt, the higher the
reimbursement from the payer.
Documentation must reflect MDM!
evaluation and management (E&M)
20. Explain what a “well rounded” clinical experience means
Includes seeing kids from birth through young adult visits for well child and acute visits,
as well as adults for wellness or acute/routine visits.
Seeing a variety of pt's, including 15% of peds and 15% of women's health of total time
in the program.
21. State the maximum number of hours that time can be spent “rounding” in a
facility
No more than 25% of total practicum hours in the program
22. State 9 things that must be documented when inputting data into clinical
encounter
Date of service
Age
Gender and ethnicity
Visit E&M code
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CC
Procedures
Tests performed and ordered
Dx
Level of involvement (mostly student, mostly preceptor, together, etc.)
23. What is the first “S” in the SNAPPS presentation?
Summarize: present the pt's H&P findings
24. What is the “N” in the SNAPPS presentation?
Narrow: based on the H&P findings, narrow down to the top 2-3 differentials
25. What is the “A” in the SNAPPS presentation?
Analyze: analyze the differentials. Compare and contrast H&P findings for each
of the differentials and narrow it down to the most likely one
26. What is the first “P” in the SNAPPS presentation?
Probe: ask the preceptor questions of anything you are unsure of.
27. What is the second “P” in the SNAPPS presentation?
Plan: come up with a specific management plan
.
28. What is the last “S” in the SNAPPS presentation?
Self-directed learning: an opportunity to investigate more about any topics that you
are uncertain of.
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